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Recurrent visible haematuria after successfully treated urinary tract infection — MSRA MCQ

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HardUrologyRecurrent visible haematuria after successfully treated urinary tract infectionMSRA

A 68-year-old woman presents with a second episode of painless visible haematuria. Three weeks ago she had dysuria, frequency and visible haematuria; urine culture grew Escherichia coli and symptoms resolved completely after culture-directed nitrofurantoin. Ten days after finishing treatment, painless visible haematuria recurred without dysuria, fever, loin pain or renal colic. Repeat urine culture shows no significant growth. She takes apixaban for atrial fibrillation; adherence is good and there has been no recent dose change. Her eGFR is 71 mL/min/1.73 m² and abdominal examination is unremarkable. What is the most appropriate next management step?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Make a suspected cancer pathway referral for urological assessment

Explanation lettering: E = shown as A · C = shown as B · A = shown as C · B = shown as E

This woman requires a suspected cancer pathway referral. NICE recommends this for adults aged 45 years and over with visible haematuria that persists or recurs after successful treatment of a urinary tract infection. Her first episode was microbiologically confirmed and resolved with culture-directed treatment; the subsequent painless visible haematuria is therefore not adequately explained by ongoing infection, particularly as the repeat culture is negative. The referral pathway addresses both bladder and renal malignancy risk. A is inappropriate because repeat testing and routine referral delay investigation despite meeting the urgent referral criterion. B is plausible because upper-tract imaging forms part of assessment, but primary-care imaging should not delay referral through the suspected cancer pathway. C would be appropriate for recurrent symptoms with evidence of persistent or recurrent infection, but there is no dysuria, systemic illness or positive culture. E is inappropriate: anticoagulation can increase the visibility or severity of bleeding but does not remove the need to investigate visible haematuria meeting cancer-referral criteria; stopping apixaban also carries thromboembolic risk and requires an indication-based assessment.

Reference: Suspected cancer: recognition and referral (NG12) — Recommendations organised by site of cancer (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer Kidney cancer quality standard QS215 — Quality statement 1: Suspected cancer pathway referral (19 March 2026) — https://www.nice.org.uk/guidance/qs215/chapter/Quality-statement-1-Suspected-cancer-pathway-referral